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APPLICATION FOR PERi91T W SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO, Telephone (209) 466-6781 ; DATE ISSUED t PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete in Triplicate) I Application is hereby made to the San Joaquin Local Health District for a permit'to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and,the Rules and Regulations of the San Joaquin Local Health District. Job Address c) AJ Jot ,N, Rps6bdivision Name Owner's Name Address Phone 9 ?� Contractor's Name <�1 #Z .e.- U �tiE ansa No. 3 Z Phone r r TYPE OF WELL/PUMP WORK: NEW WELL 54-, _ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ( SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK 1 �] SEWER LINES DISPOSAL FLD, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PI-Ts/SUMPS _ I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I J Industrial ,6pen Bottom ❑ Manteca Dia. of Well Excavation / ? mestidl,Pri.va.te ` Gra.ve] Pack Well -Casing. Publ ic.rLj. Other ❑ Del a -•�,.� Irrigation Type of Casing E i 9 Approx. astern Specifications [J_ Cathodic Protection Depth Depth of Grout Seal ` a 17 Geophysical 2 ' Type of Grout I - K ❑Other Surface Seal Installed by Repair Work Done ❑ Type of Pump rL&et H.P. "> State Work Done Well Destruction U Well Diameter Sealing Material (top 501) Depth Filler Material (Below 50') ^' ' TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic tank orseepage pit permitted if public sewer is I '\1 available within 200 feet.) Installation will serve: Residence _ Commercial _ Other Number of living units: Number of bedrooms Lot size Character ofsoil to a depth of 3 feet: Water table depth rt SEPTIC'TANK ED Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal t SEWAGE SYSTEM Distance to nearest: Well Foundation ' Property Line DESTRUCTION LEACHING LINE U No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS U Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ �,,rA I hereby certify-Ythat-IThave prepared'this'applicationnand�that the work will be done in accordance with San Joaquin county ` ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensation laws of California." The applicant must-calall. for 11 requiredins ection's. Complete drawing on reverse side. Signed X - Title: Date: FOR DVIAk E ONLY Application Accepted by Area ❑ Stk 466-6781 Additional Comments: �di 369-3621 Pit or Grout Inspection Ay 10 DateL-1Manteca 823-7104 Final Inspection by rw Date ❑ Tracy 835-6385 Applicant - Return all copi s t Environme al Health`°Permit/Services 16 1 E. Hazelton Ave., P.O. Box 2009, Stk., CA .95201 FEE BASE AMOUNT DUE AMOUNT REMITTED Ga �E VED BY -L'DATE PERMIT NO. INFO � k l c o� os. c�J �/ s -� � X38 - Sys }it EH 13-24 REV. 10/82 14-.26 "• 1.11.E�.a � �/vj �• r 'i